MC2

A woman is 8 months pregnant. She tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. Which response by the nurse is most appropriate? "Many women imagine what their baby is like." "A baby in utero does respond to the mother's voice." "You'll need to ask the doctor if the baby can hear yet." "Thinking that your baby hears will help you bond with the baby."

"A baby in utero does respond to the mother's voice."

What symptom described by a woman is characteristic of premenstrual syndrome (PMS)? "I feel irritable and moody a week before my period is supposed to start." "I have lower abdominal pain beginning the third day of my menstrual period." "I have nausea and headaches after my period starts, and they last 2 to 3 days." "I have abdominal bloating and breast pain after a couple of days of my period."

"I feel irritable and moody a week before my period is supposed to start."

It is time to give a 3-year-old boy his medication. Which approach is MOST likely to receive a positive response? "It is time for your medication now. Would you like water or apple juice afterward?" "Would not you like to take your medicine?" "You must take your medicine, because the doctor says it will make you better." "See how nicely this boy took his medicine? Now take yours."

"It is time for your medication now. Would you like water or apple juice afterward?"

A couple has been counseled for genetic anomalies. They ask you, "What is karyotyping?" Your best response is: "Karyotyping will reveal if the baby's lungs are mature." "Karyotyping will reveal if your baby will develop normally." "Karyotyping will provide information about the gender of the baby, and the number and structure of the chromosomes." "Karyotyping will detect any physical deformities the baby has."

"Karyotyping will provide information about the gender of the baby, and the number and structure of the chromosomes."

A woman's cousin gave birth to an infant with a congenital heart anomaly. The woman asks the nurse when such anomalies occur during development. Which response by the nurse is most accurate? "We don't really know when such defects occur." "It depends on what caused the defect." "They occur between the third and fifth weeks of development." "They usually occur in the first 2 weeks of development."

"They occur between the third and fifth weeks of development."

An expectant father confides in the nurse that his pregnant wife, 10 weeks of gestation, is driving him crazy. "One minute she seems happy, and the next minute she is crying over nothing at all. Is there something wrong with her?" The nurse's BEST response would be: "This is normal behavior and should begin to subside by the second trimester." "She may be having difficulty adjusting to pregnancy; I will refer her to a counselor that I know." "This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant." "You seem impatient with her. Perhaps this is precipitating her behavior."

"This is called emotional lability and is related to hormone changes and anxiety during pregnancy. The mood swings will eventually subside as she adjusts to being pregnant."

List the time span in lunar months, calendar months, weeks, and days that indicates the appropriate length for a normal pregnancy._

10 lunar months, 9 calendar months, 40 weeks, 280 days.

A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer?

13

A toddler with hemophilia is being discharged from the hospital. which teaching should the nurse include in the discharge instruction to monitor. A) apply padding on the sharp corners of furniture. B) prevent the child from running inside the house. C) give ASA 81 mg for pain D) use a soft bristle toothbrush for frequent cleaning.

A) apply padding on the sharp corners of furniture.

A community women's health nurse knows that which groups of people are considered vulnerable populations? (Select all that apply.) Caucasian Americans Adolescent girls Women with underlying health conditions Refugee women Incarcerated women

Adolescent girls Women with underlying health conditions Refugee women Incarcerated women

43. A child with leukemia is admitted for Chemotherapy and the nursing diagnosis " altered nutrion, less those body requirements related to anorexia, nausea and vomiting" is identified. Which intervention the nurse included in this child plan of care?

Allow the child to eat any food desired and tolerated.

The nurse is planning care for a patient with a different cultural background. What would be an appropriate goal? Strive to keep the patient's cultural background from influencing health needs. Encourage the continuation of cultural practices in the hospital setting. In a nonjudgmental way attempt to change the patient's cultural beliefs. As necessary adapt the patient's cultural practices to her health needs.

As necessary adapt the patient's cultural practices to her health needs.

The nurse should include which information when teaching a 15-year old about genital tract infection prevention? (Select all that apply.) Select all that apply. Wear nylon undergarments Avoid tight-fitting jeans Use floral scented bath salts Decrease sugar intake Do not douche. Limit time spent wearing a wet bathing suit

Avoid tight-fitting jeans Decrease sugar intake Do not douche. Limit time spent wearing a wet bathing suit

w should the nurse respond to the concerned parents of 15 month old who is not yet able to self-feed with a spoon. A) tell parents to guide the childs hand when using spoons. B) suggest using foods that can be eaten with fingers. C) discuss possible causes of delay with self feeding D)encourage longer mealtimes to practice eating with a spoon

B) suggest using foods that can be eaten with fingers.

Which health risk is not associated with menopause? Osteoporosis Coronary heart disease Breast cancer Obesity.

Breast cancer

an infant who has been diagnosed with tracheoesophageal fistula. what nursing intervention is indicated for this infant prior to surgical repair A) provide frequent sips of water. B) give isotonic enemas as prescribed. C) maintain NPO status D) prepare the infant for barium enema.

C) maintain NPO status

the nurse is using the ages and stages questionnaire t assess a 24 month old. what is the best intervention for the nurse to initiate after assessment is completed. A) provide the parents with a list of stimulating activities. B)assess for changes in the vital signs. C) meet with a social worker to review the results D) review the childs childs birth history

C) meet with a social worker to review the results

The nurse should teach a pregnant woman that which substances are teratogens? (Select all that apply.) Select all that apply. Cigarette smoke Isotretinoin (Retin A) Vitamin C Salicylic acid Rubella

Cigarette smoke Isotretinoin (Retin A) Rubella

a child is diagnosed with irritable bowel disease. her mother is concerned that she will experience developmental delays as a result of this disorder. how should the nurse respond. A)growth failure is a concern but develoment delays are not likely to occur B) schedule a private tutor to help prevent developmental delays C) she will only experience delays if weight loss can not be controlled. D) she is at high risk for a number of different problems including developmental delays

D) she is at high risk for a number of different problems including developmental delays

when providing care for a child who is in balanced suspension skeletal traction using a thomas splint and pearson attachment to the right femur, which intervention is most important for the nurse to implement. A)assess skin for redness and signs of tissue breakdown B) change position every 2 hours C)cleanse pin sites as prescribed D)monitor peripheral pulses and sensation in the right leg.

D)monitor peripheral pulses and sensation in the right leg.

The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? Doppler blood flow analysis Contraction stress test (CST) Amniocentesis Daily fetal movement counts

Doppler blood flow analysis

In which culture is the father more likely to be expected to participate in the labor and delivery? Asian-American African-American European-American Hispanic

European-American

The nurse assesses the neonate immediately after birth. A tracheoesophageal fistula should be suspected if what condition is present? Jaundice Clubfeet Absence of sucking Excessive amount of frothy saliva in the mouth

Excessive amount of frothy saliva in the mouth

A mother's household consists of her husband, his mother, and another child. She is living in a/an: extended family. single-parent family. married-blended family trinuclear family.

Extended Family

During a client's physical examination, the nurse notes that the lower uterine segment is soft on palpation. The nurse would document this finding as: Hegar sign. McDonald sign. Chadwick sign. Goodell sign.

Hegar sign.

Which statement is most likely to be associated with a breech presentation? Least common malpresentation Descent is rapid Diagnosis by ultrasound only High rate of neuromuscular disorders

High rate of neuromuscular disorders

What factor predisposes an infant to fluid imbalances? Decreased surface area Lower metabolic rate Immature kidney functioning Decreased daily exchange of extracellular fluid

Immature kidney functioning

What diet would be appropriate for the child with celiac disease? Salt free Phenylalanine free Low gluten High calories, low protein, low fat

Low gluten

1. A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first?

Place the infant on the abdomen to protect the sac.

What laboratory results would be a cause for concern if exhibited by a woman at her first prenatal visit during the second month of her pregnancy? Hematocrit 38%, hemoglobin 13 g/dL White blood cell count 6000/mm3 Platelets 300,000/mm3 Rubella titer 1:6

Rubella titer 1:6

The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What action should the nurse include? Informing her that bed rest is important until 1 week after the icteric phase. Telling her that the child should not return to school until 3 weeks after icteric phase. Giving reassurance that hepatitis A cannot be transmitted to other family members. Teaching infection control measures to family members.

Teaching infection control measures to family members.

Which statements about multifetal pregnancy are most appropriate? (Select all that apply.) Select all that apply. The expectant mother often develops anemia because the fetuses have a greater demand for iron. Twin pregnancies come to term with the same frequency as single pregnancies. The mother should be counseled to increase her nutritional intake and gain more weight. Backache and varicose veins are often more pronounced. Spontaneous rupture of membranes before term is uncommon.

The expectant mother often develops anemia because the fetuses have a greater demand for iron. The mother should be counseled to increase her nutritional intake and gain more weight. Backache and varicose veins are often more pronounced.

On completion of a vaginal examination on a laboring woman, the nurse records: 50%, 6 cm, -1. What is a correct interpretation of the data? The fetal presenting part is 1 cm above the ischial spines. Effacement is 4 cm from completion. Dilation is 50% completed. The fetus has achieved passage through the ischial spines.

The fetal presenting part is 1 cm above the ischial spines.

A nurse is reviewing information related to home pregnancy tests so as to prepare for a patient teaching session. Which statement by the patient indicates that additional instruction is needed following the teaching session? The patient states that she will follow directions as listed on the testing package. The patient indicates that a positive result will be seen if there is a color change on the applicator. The patient states there is no need for concern as home pregnancy test results are 100% correct. The patient can perform the test without any assistance in the home setting.

The patient states there is no need for concern as home pregnancy test results are 100% correct.

Following a code situation in the clinical setting when the patient expires regardless of intervention, the nursing/medical staff takes a moment to reflect. What is the name for this type of reflection? The break The pause The reflection The designated time out

The pause

Which is correct concerning the performance of a Papanicolaou (Pap) smear? The woman should not douche, use vaginal medications, or have intercourse for at least 24 hours before the test. It should be performed once a year beginning with the onset of puberty. A lubricant such as Vaseline should be used to ease speculum insertion. The specimen for the Pap smear should be obtained after specimens are collected for cervical infection.

The woman should not douche, use vaginal medications, or have intercourse for at least 24 hours before the test.

A 22-year-old woman pregnant with a single fetus has a preconception body mass index (BMI) of 24. When she was seen in the clinic at 14 weeks of gestation, she had gained 1.8 kg (4 lbs) since conception. How would the nurse interpret this? This weight gain indicates possible gestational hypertension. This weight gain indicates that the woman's infant is at risk for intrauterine growth restriction (IUGR). This weight gain cannot be evaluated until the woman has been observed for several more weeks. The woman's weight gain is appropriate for this stage of pregnancy.

The woman's weight gain is appropriate for this stage of pregnancy.

A 40-year-old woman with a body mass index (BMI) indicating clinical obesity is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time to assess the status of the pregnancy? Biophysical profile Amniocentesis Maternal serum alpha-fetoprotein (MSAFP) Transvaginal ultrasound

Transvaginal ultrasound

The nurse is caring for an infant with a tracheostomy when accidental decannulation occurs. The nurse is unable to reinsert the tube. What should be the NEXT action by the nurse? Notifying the surgeon Performing oral intubation Trying to insert a larger-size tube Trying to insert smaller-size tube

Trying to insert smaller-size tube

Therapeutic management of the child with inflammatory bowel disease (IBD) includes a diet that has which component? Low protein Low calorie High fiber Vitamin supplements

Vitamin supplements

The women's health nurse knows which statements regarding sexual response are accurate? (Select all that apply.) Select all that apply. Women and men are more alike than different in their physiologic response to sexual arousal and orgasm. Vasocongestion is the congestion of blood vessels. The orgasmic phase is the final state of the sexual response cycle. Facial grimaces and spasms of hands and feet are often part of arousal. Sexual difficulties should be disregarded in the after birth period.

Women and men are more alike than different in their physiologic response to sexual arousal and orgasm. Vasocongestion is the congestion of blood vessels. Facial grimaces and spasms of hands and feet are often part of arousal.

A nurse is caring for a client whose labor is being augmented with oxytocin. The nurse recognizes that the oxytocin should be discontinued immediately if there is evidence of: uterine contractions occurring every 8 to 10 minutes a fetal heart rate (FHR) of 180 with absence of variability. the client needing to void. rupture of the client's amniotic membranes.

a fetal heart rate (FHR) of 180 with absence of variability.

43. A pregnant woman with hypermesis gravidarium, what is the best nurse intervention.

administer prescribed IV solution

One of the goals for children with asthma is to prevent respiratory infection. This is because respiratory infection: lessens effectiveness of medications. encourages exercise-induced asthma. increases sensitivity to allergens. can trigger an episode or aggravate an asthmatic state.

can trigger an episode or aggravate an asthmatic state.

1. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take?

check the infants blood sugar

What treatment that should be considered first for the client with von Willebrand disease who experiences a after birth hemorrhage is: cryoprecipitate. factor VIII and vWf. desmopressin. Hemabate.

desmopressin.

During the first trimester the pregnant woman would be most motivated to learn about: fetal development. impact of a new baby on family members. measures to reduce nausea and fatigue so she can feel better. location of childbirth preparation and breastfeeding classes.

measures to reduce nausea and fatigue so she can feel better.

A maternal serum alpha-fetoprotein (MSAFP) test is performed at 16 to 18 weeks of gestation. An elevated level has been associated with: Down syndrome. sickle cell anemia. cardiac defects. open neural tube defects such as spina bifida.

open neural tube defects such as spina bifida.

The priority nursing intervention when a nurse observes profuse after birth bleeding is to: call the woman's primary health care provider. administer the standing order for an oxytocic. palpate the uterus and massage it if it is boggy. assess maternal blood pressure and pulse for signs of hypovolemic shock.

palpate the uterus and massage it if it is boggy.

After birth women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the after birth woman would be to: acidify the urine by drinking three glasses of orange juice each day. maintain a fluid intake of 1 to 2 L/day. empty her bladder every 4 hours throughout the day. perform perineal care on a regular basis.

perform perineal care on a regular basis.

The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. An important consideration in managing the child's pain is to: give only an opioid analgesic at this time. increase the dosage of analgesic until the child is adequately sedated. plan a preventive schedule of pain medication around the clock. give the child a clock and explain when he or she can have pain medications.

plan a preventive schedule of pain medication around the clock.

The parent of a child with cystic fibrosis calls the clinic nurse to report that the child has developed tachypnea, tachycardia, dyspnea, pallor, and cyanosis. The nurse should tell the parent to bring the child to the clinic because these symptoms are suggestive of: pneumothorax. bronchodilation. carbon dioxide retention. increased viscosity of sputum.

pneumothorax.

An immediate intervention when an infant chokes on a piece of food would be to: have infant lie quietly while a call is placed for emergency help. position the infant in a head-down, face-down position and administer five quick blows between the shoulder blades. administer mouth-to-mouth resuscitation. give water by cup to relieve the obstruction.

position the infant in a head-down, face-down position and administer five quick blows between the shoulder blades.

When providing care to a young single woman just diagnosed with acute pelvic inflammatory disease, the nurse should: -point out that inappropriate sexual behavior caused the infection. -position the woman in a semi-Fowler position. -explain to the woman that infertility is a likely outcome of this type of infection. -tell her that antibiotics need to be taken until pelvic pain is relieved.

position the woman in a semi-Fowler position.

A child has a nasogastric (NG) tube inserted after surgery for acute appendicitis. The purpose of the NG tube is to: maintain electrolyte balance. maintain an accurate record of output. prevent the spread of infection. prevent abdominal distention.

prevent abdominal distention.

A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called a: primipara. primigravida. multipara. nulligravida.

primipara.

The nurse should tell a primigravida that the definitive sign indicating that labor has begun would be: progressive uterine contractions with cervical change. lightening. rupture of membranes. passage of the mucous plug (operculum).

progressive uterine contractions with cervical change.

When caring for a child after a tonsillectomy, the nurse should: watch for continuous swallowing. encourage gargling to reduce discomfort. position the child on the back for sleeping. apply warm compresses to the throat.

watch for continuous swallowing.

A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? · Pain level · Blood pressure · Infusion site · Contraction pattern

· Contraction pattern

A pregnant woman at 10 weeks of gestation jogs 3 or 4 times per week. She is concerned about the effect of exercise on the fetus. The nurse should inform her: "You do not need to modify your exercising any time during your pregnancy." "Stop exercising, because it will harm the fetus." "You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month." "Jogging is too hard on your joints; switch to walking now."

"You may find that you need to modify your exercise to walking later in your pregnancy, around the seventh month."

43. A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?

Ask the mother to stop feeding, confront the infant, and then assist the mother to help the baby latch on.

The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? · Respiratory rate of 22 breaths/min · A large amount of lochia rubra · Blood pressure 149/90 · Positive Homan's sign

140/90

A woman is 6 weeks pregnant. She has had a previous spontaneous abortion at 14 weeks of gestation and a pregnancy that ended at 38 weeks with the birth of a stillborn girl. What is her gravidity and parity using the GTPAL system? _.

3-1-0-1-0

Which hematocrit (Hct) and hemoglobin (Hgb) results represent(s) the lowest acceptable values for a woman in the third-trimester of pregnancy? 38% Hct; 14 g/dL Hgb 35% Hct; 13 g/dL Hgb 33% Hct; 11 g/dL Hgb 32% Hct; 10.5 g/dL Hgb

33% Hct; 11 g/dL Hgb

A pregnant woman is the mother of two children. Her first pregnancy ended in a still birth at 32 weeks of gestation, her second pregnancy with the birth of her daughter at 36 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the 5-digit system to describe this woman's current obstetric history, the nurse would record _.

4-1-2-0-2

The student nurse is giving a presentation about milestones in embryonic development. Which information should be included? At 8 weeks of gestation, primary lung and urethral buds appear. At 12 weeks of gestation, the vagina is open or the testes are in position for descent into the scrotum. At 20 weeks of age, the vernix caseosa and lanugo appear. At 24 weeks of age, the skin is smooth, and subcutaneous fat is beginning to collect.

At 20 weeks of age, the vernix caseosa and lanugo appear.

What is descriptive of the family systems theory? a. The family is viewed as the sum of individual members. b. When the family system is disrupted, change can occur at any point in the system. c. Change in one family member cannot create change in other members. d. Individual family members are readily identified as the source of a problem.

B. When the family system is disrupted, change can occur at any point in the system.

A woman who is 14 weeks pregnant tells the nurse that she always had a glass of wine with dinner before she became pregnant. She has abstained during her first trimester and would like to know if it is safe for her to have a drink with dinner now. The nurse tells her: -Because you are in your second trimester, there is no problem with having one drink with dinner. -One drink every night is too much. One drink 3 times a week should be fine. -Because you are in your second trimester, you can drink as much as you like. -Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy.

Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is to abstain throughout your pregnancy.

The nurse is assessing a woman's breast self-examination (BSE) technique. Which action indicates that a woman needs further instruction regarding BSE? Performs every month on the first day of her menstrual period Uses the pads of her fingers when palpating each breast Inspects her breasts while standing before a mirror and changing arm positions Places a folded towel under right shoulder and right hand under head when palpating right breast

Performs every month on the first day of her menstrual period

A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be: constipation. alteration in the pattern of fetal movement. heart palpitations. edema in the ankles and feet at the end of the day.

alteration in the pattern of fetal movement.

A pregnant woman's last menstrual period began on April 8, 2009, and ended on April 13. Using Nägele's rule, her estimated date of birth would be _.

January 15, 2010

What should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia? Liver transplantation may be needed eventually. Death usually occurs by 6 months of age. Prognosis for a full recovery is excellent. Children with surgical correction live normal lives.

Liver transplantation may be needed eventually.

Which after birth infection is most often contracted by first-time mothers who are breastfeeding? Endometritis Wound infections Mastitis Urinary tract infections (UTIs)

Mastitis

43. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide?

Maternal blood pressure

A key finding from the Human Genome Project is: -approximately 20,000 to 25,000 genes make up the genome. -all human beings are 80.99% identical at the DNA level. -human genes produce only one protein per gene; other mammals produce three proteins per gene. -single-gene testing will become a standardized test for all pregnant women in the future.

approximately 20,000 to 25,000 genes make up the genome.

The nurse should include questions regarding sexuality when gathering data for a reproductive health history of a female patient. Which principle should guide the nurse when interviewing the patient? An in-depth exploration of specific sexual practices should be included for every patient. Sexual histories are optional if the patient is not currently sexually active. Misconceptions and inaccurate information expressed by the patient should be corrected promptly. Questions regarding the patient's sexual relationship are unnecessary if she is monogamous.

Misconceptions and inaccurate information expressed by the patient should be corrected promptly.

The nurse is taking care of a family that includes parents, maternal grandparents and children residing in one home. Which family unit this represent? Nuclear family Extended family Multigenerational family Married blended family

Multigenerational family

A child with asthma is having pulmonary function tests. The purpose of the peak expiratory flow rate (PEFR) is to: confirm the diagnosis of asthma. determine the cause of asthma. identify "triggers" of asthma. assess the severity of asthma.

assess the severity of asthma.

The nurse is caring for an infant who is suspected to have neonatal sepsis. Which neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to observe? Large for gestational age (LGA) and an infant of a diabetic mother Small for gestational age (SGA) and intrauterine growth restriction Singleton gestation and female Multiple gestation and low birth weight

Multiple gestation and low birth weight

The nurse needs to take the blood pressure of a preschool boy for the first time. Which action would be BEST in gaining his cooperation? Taking his blood pressure when a parent is there to comfort him. Telling him that this procedure will help him get well faster. Explaining to him how the blood flows through the arm and why the blood pressure is important. Permitting him to handle equipment and see the dial move before putting the cuff in place.

Permitting him to handle equipment and see the dial move before putting the cuff in place.

What would a breastfeeding mother who is concerned that her baby is not getting enough to eat find most helpful and most cost-effective on the day after discharge? Visiting a pediatric screening clinic at the hospital Placing a call to the hospital nursery "warm line" Calling the pediatrician for a lactation consult referral Requesting a home visit

Placing a call to the hospital nursery "warm line"

When assessing the fetal heart rate (FHR) of a woman at 30 weeks of gestation, the nurse counts a rate of 82 beats/min. Initially the nurse should: recognize that the rate is within normal limits and record it. assess the woman's radial pulse. notify the physician. allow the woman to hear the heartbeat.

assess the woman's radial pulse.

The nurse is caring for a 12-year-old child who sustained major burns when putting charcoal lighter on a campfire. The nurse observes that the child is "very brave" and appears to accept pain with little or no response. What is the most appropriate nursing action? Request a psychological consultation. Ask why the child does not have pain. Praise the child for the ability to withstand pain. Encourage continued bravery as a coping strategy.

Request a psychological consultation.

The term used to describe a situation in which a cultural group loses its identity and becomes part of the dominant culture is called A. assimilation B. Cultural relativism C. Ethnocentrism D. acculturation

assimilation.

During the preconception phase, the nurse should teach about which infectious diseases as risk factors for maternal complications? (Select all that apply.) Select all that apply. Diabetes Rubella Hepatitis B Anemia HIV/AIDS

Rubella Hepatitis B HIV/AIDS

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: hypertonia, tachycardia, and metabolic alkalosis. abdominal distention, temperature instability, and grossly bloody stools. hypertension, absence of apnea, and ruddy skin color. scaphoid abdomen, no residual with feedings, and increased urinary output.

abdominal distention, temperature instability, and grossly bloody stools.

With regard to abnormalities of chromosomes, nurses should be aware that: they occur in approximately 10% of newborns. abnormalities of number are the leading cause of pregnancy loss. down syndrome is a result of an abnormal chromosomal structure. unbalanced translocation results in a mild abnormality that the child will outgrow.

abnormalities of number are the leading cause of pregnancy loss.

Which laboratory test result would be a cause for concern if exhibited by an Rh-positive newborn 12 hours after birth? Direct Coombs': Negative Hematocrit (Hct): 58% and hemoglobin (Hgb): 18 g/dL Blood glucose level: 55 mg/dL Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratory (VDRL): Reactive

Blood glucose level: 55 mg/dL

A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? · Carrots · Chicken · Yogurt · Cheese

Chicken

1. During a routine clinic visit, the nurse determines that a 5-year-old boy's blood pressure is 112/70. When calculating the child's blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next?

Compare the child's blood pressure with readings from previous visits.

If exhibited by an expectant father, what would be a warning sign of ineffective adaptation to his partner's first pregnancy? -Views pregnancy with pride as a confirmation of his virility. -Consistently changes the subject when the topic of the fetus/newborn is raised. -Expresses concern that he might faint at the birth of his baby. -Experiences nausea and fatigue, along with his partner, during the first trimester.

Consistently changes the subject when the topic of the fetus/newborn is raised.

What best describes the pattern of genetic transmission known as autosomal recessive inheritance? Disorders in which the abnormal gene for the trait is expressed even when the other member of the pair is normal. Disorders in which both genes of a pair must be abnormal for the disorder to be expressed. Disorders in which a single gene controls the particular trait. Disorders in which the abnormal gene is carried on the X chromosome.

Disorders in which both genes of a pair must be abnormal for the disorder to be expressed.

If exhibited by a pregnant woman, what represents a positive sign of pregnancy? Morning sickness Quickening Positive pregnancy test Fetal heartbeat auscultated with Doppler/fetoscope

Fetal heartbeat auscultated with Doppler/fetoscope

Which presumptive signs (felt by the woman) or probable sign (observed by the examiner) of pregnancy is not matched with another possible cause? Amenorrhea: Stress, endocrine problems Quickening: Gas, peristalsis Goodell sign: Cervical polyps Chadwick sign: Pelvic congestion

Goodell sign: Cervical polyps

The nurse-midwife is teaching a group of women who are pregnant, including instruction on Kegel exercises. Which statement by a participant would indicate a correct understanding of the instruction? I will only see results if I perform 100 Kegel exercises each day. I should hold the Kegel exercise contraction for 10 seconds and rest for 10 seconds between exercises. I should only perform Kegel exercises in the sitting position. I will perform daily Kegel exercises during the last trimester of my pregnancy to achieve the best results.

I should hold the Kegel exercise contraction for 10 seconds and rest for 10 seconds between exercises.

The nurse observes erythema, pain, and edema at a child's intravenous (IV) site with streaking along the vein. What should the nurse do FIRST? Immediately stop the infusion. Check for a good blood return. Ask another nurse to check the IV site. Increase the intravenous (IV) drip for 1 minute and recheck.

Immediately stop the infusion.

Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester? Less audible heart sounds (S1, S2) Increased pulse rate Increased blood pressure Decreased red blood cell (RBC) production

Increased pulse rate

The nurse is reviewing laboratory values to determine Rh incompatibility between mother and fetus. The nurse should assess which specific lab result? Indirect Coombs' test Hemoglobin level hCG (human chorionic gonadotrophin) level Maternal serum alpha-fetoprotein (MSAFP)

Indirect Coombs' test

Which after birth conditions are considered medical emergencies that require immediate treatment? Inversion of the uterus and hypovolemic shock Hypotonic uterus and coagulopathies Subinvolution of the uterus and idiopathic thrombocytopenic purpura Uterine atony and disseminated intravascular coagulation (DIC)

Inversion of the uterus and hypovolemic shock

Which minerals and vitamins usually are recommended as a supplement a pregnant woman's diet? Fat-soluble vitamins A and D Water-soluble vitamins C and B6 Iron and folate Calcium and zinc

Iron and folate

A maternity nurse should be aware of which fact about amniotic fluid? It serves as a source of oral fluid and as a repository for waste from the fetus. The volume remains about the same throughout the term of a healthy pregnancy. A volume of less than 300 mL is associated with gastrointestinal malformations. A volume of more than 2 L is associated with fetal renal abnormalities.

It serves as a source of oral fluid and as a repository for waste from the fetus.

Which personal safety precaution should guide the nurse working in home care? Do not carry personal items, such as extra car keys or a cellular phone. Avoid making a visit with another nurse. Schedule visits during daylight hours. Never wear a name tag.

Schedule visits during daylight hours.

A nurse counseling a client with endometriosis understands which statements regarding the management of endometriosis is accurate? (Select all that apply.) Select all that apply. -Bone loss from hypoestrogenism is not reversible. -Side effects from the steroid danazol include masculinizing traits. -Surgical intervention often is needed for severe or acute symptoms. -Women without pain and who do not want to become pregnant need no treatment. -Women with mild pain who may want a future pregnancy may take nonsteroidal antiinflammatory drugs (NSAIDs).

Side effects from the steroid danazol include masculinizing traits. Surgical intervention often is needed for severe or acute symptoms. Women without pain and who do not want to become pregnant need no treatment.

A 42-year-old woman asks the nurse about mammograms, now that she is "getting older." Which information provided by the nurse would not be correct given current American Cancer Society recommendations? The American Cancer Society recommends mammograms every 1 to 2 years for women ages 40 to 49. A mammogram is considered to be an imaging study. Even if one has a mammogram, this does not preclude the individual from performing breast self-examination (BSE). Mammograms can confirm the diagnosis for breast cancer.

The American Cancer Society recommends mammograms every 1 to 2 years for women ages 40 to 49.

The nurse is preparing a plan to teach a mother how to administer 1½ teaspoons of medicine to her 6-month-old child. The nurse should recommend using: a household measuring spoon. a regular silverware teaspoon. a paper cup measure in 5-mL increments. a plastic syringe (without needle) calibrated in milliliters.

a plastic syringe (without needle) calibrated in milliliters.

Prior to the patient undergoing amniocentesis, the most appropriate nursing intervention is to: administer RhoD immunoglobulin. administer anticoagulant. send the patient for a computed tomography (CT) scan before the procedure. assure the mother that short-term radiation exposure is not harmful to the fetus.

administer RhoD immunoglobulin.

A newborn yellow abdomen and chest what to you assess

bilirubin level

A primigravida asks the nurse about signs she can look for that would indicate that the onset of labor is getting closer. The nurse should describe: weight gain of 1 to 3 lbs. quickening. fatigue and lethargy. bloody show.

bloody show.

With regard to nutritional needs during lactation, a maternity nurse should be aware that: the mother's intake of vitamin C, zinc, and protein now can be lower than during pregnancy. caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful. critical iron and folic acid levels must be maintained. lactating women can go back to their prepregnant calorie intake.

caffeine consumed by the mother accumulates in the infant, who therefore may be unusually active and wakeful.

In order to reassure and educate pregnant clients about changes in their blood pressure, maternity nurses should be aware that: -a blood pressure cuff that is too small produces a reading that is too low; a cuff that is too large produces a reading that is too high. -shifting the client's position and changing from arm to arm for different measurements produces the most accurate composite blood pressure reading at each visit. -the systolic blood pressure increases slightly as pregnancy advances; the diastolic pressure remains constant. -compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the latter stage of term pregnancy.

compression of the iliac veins and inferior vena cava by the uterus contributes to hemorrhoids in the latter stage of term pregnancy.

When counseling a client about getting enough iron in her diet, the maternity nurse should tell her that: milk, coffee, and tea aid iron absorption if consumed at the same time as iron. iron absorption is inhibited by a diet rich in vitamin C. iron supplements are permissible for children in small doses. constipation is common with iron supplements.

constipation is common with iron supplements.

A 2-month-old breastfed infant is successfully rehydrated with oral rehydration solutions for acute diarrhea. Instructions to the mother about breastfeeding should include to: continue breastfeeding. stop breastfeeding until breast milk is cultured. stop breastfeeding until diarrhea is absent for 24 hours. express breast milk and dilute with sterile water before feeding.

continue breastfeeding.

A 65-year-old woman, G6 P6006, is complaining of increasing stress incontinence and pelvic pressure and fullness. Pelvic examination reveals a bulging in the anterior vaginal wall. This woman is most likely experiencing: uterine prolapse. rectocele. cystocele. vesicovaginal fistula.

cystocele.

A Native American woman gave birth to a baby girl 12 hours ago. The nurse notes that the woman keeps her baby in the bassinet except for feeding and states that she will wait until she gets home to begin breastfeeding. The nurse recognizes that this behavior is most likely a reflection of: a. delayed attachment. b. embarrassment. c. disappointment that the baby is a girl. d. a belief that babies should not be fed colostrum.

d. a belief that babies should not be fed colostrum.

An effective relief measure for primary dysmenorrhea would be to: reduce physical activity level until menstruation ceases. begin taking prostaglandin synthesis inhibitors on the first day of the menstrual flow. decrease intake of salt and refined sugar about 1 week before menstruation is about to occur. use barrier methods rather than the oral contraceptive pill (OCP) for birth control.

decrease intake of salt and refined sugar about 1 week before menstruation is about to occur.

A nurse is providing genetic counseling for an expectant couple who already have a child with trisomy 18. The nurse should: -tell the couple they need to have an abortion within 2 to 3 weeks. -explain that the fetus has a 50% chance of having the disorder. -discuss options with the couple, including amniocentesis to determine whether the fetus is affected. -refer the couple to a psychologist for emotional support.

discuss options with the couple, including amniocentesis to determine whether the fetus is affected.

The Center for Disease Control (CDC) recommended medication for the treatment of chlamydia would be: doxycycline. podofilox. acyclovir. penicillin.

doxycycline.

A pregnant woman experiencing nausea and vomiting should: drink a glass of water with a fat-free carbohydrate before getting out of bed in the morning. eat small, frequent meals (every 2 to 3 hours). increase her intake of high-fat foods to keep the stomach full and coated. limit fluid intake throughout the day.

eat small, frequent meals (every 2 to 3 hours).

The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? · Begin a training program lifting weights and running · Splint affected joints during activity · Exercise in a swimming pool · Perform passive range of motion exercises twice daily

exercise in a swimming pool

Self-care instructions for a woman following a modified radical mastectomy would include that she: -wears clothing with snug sleeves to support her affected arm. -use depilatory creams instead of shaving the axilla of her affected arm. -expect a decrease in sensation or tingling in her affected arm as her body heals. -empty surgical drains once a day or every other day.

expect a decrease in sensation or tingling in her affected arm as her body heals.

During a health history interview, a woman states that she thinks that she has "bumps" on her labia. She also states that she is not sure how to check herself. The correct response would be to: reassure the woman that the examination will not reveal any problems. explain the process of vulvar self-examination to the woman and reassure her that she will become familiar with normal and abnormal findings during the examination. reassure the woman that "bumps" can be treated. reassure her that most women have "bumps" on their labia.

explain the process of vulvar self-examination to the woman and reassure her that she will become familiar with normal and abnormal findings during the examination.

When obtaining a reproductive health history from a female patient, the nurse should: limit the time spent on exploration of intimate topics. avoid asking questions that may embarrass the patient. use only accepted medical terminology when referring to body parts and functions. explain the purpose for the questions asked and how the information will be used.

explain the purpose for the questions asked and how the information will be used.

A pregnant woman demonstrates understanding of the nurse's instructions regarding relief of leg cramps if she: wiggles and points her toes during the cramp. applies cold compresses to the affected leg. extends her leg and dorsiflexes her foot during the cramp. avoids weight bearing on the affected leg during the cramp.

extends her leg and dorsiflexes her foot during the cramp.

The most consistent indicator of pain in infants is: increased respirations. increased heart rate. clenching the teeth and lips. facial expression of discomfort.

facial expression of discomfort.

A nurse teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The woman demonstrates an understanding of the nurse's instructions if she states that a positive sign of pregnancy is: a positive pregnancy test. fetal movement palpated by the nurse-midwife. Braxton Hicks contractions. quickening.

fetal movement palpated by the nurse-midwife.

Standard Precautions for infection control include that: gloves are worn any time a patient is touched. needles are capped immediately after use and disposed of in a special container. gloves are worn to change diapers when there are loose or explosive stools. masks are needed only when caring for patients with airborne infections.

gloves are worn to change diapers when there are loose or explosive stools.

With regard to the classification of neonatal bacterial infection, nurses should be aware that: congenital infection progresses slower than health care-associated infection. health care-associated infection can be prevented by effective handwashing. infections occur with about the same frequency in boy and girl infants, although female mortality is higher. the clinical sign of a rapid, high fever makes infection easier to diagnose.

health care-associated infection can be prevented by effective handwashing.

An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: birth injury. hypocalcemia. hypoglycemia. seizures.

hypoglycemia.

An expectant couple asks the nurse about intercourse during pregnancy and if it is safe for the baby. The nurse should tell the couple that: intercourse should be avoided if any spotting from the vagina occurs afterward. intercourse is safe until the third trimester. safer-sex practices should be used once the membranes rupture. intercourse and orgasm are often contraindicated if a history or signs of preterm labor are present.

intercourse and orgasm are often contraindicated if a history or signs of preterm labor are present.

Women with an inadequate weight gain during pregnancy are at higher risk of giving birth to an infant with: spina bifida. intrauterine growth restriction. diabetes mellitus. Down syndrome.

intrauterine growth restriction.

A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): sometimes uses vibroacoustic stimulation. is an invasive test; however, contractions are stimulated. is considered negative if no late decelerations are observed with the contractions. is more effective than nonstress test (NST) if the membranes have already been ruptured.

is considered negative if no late decelerations are observed with the contractions.

The best explanation for why pulse oximetry is used on young children is that it: is noninvasive. is better than capnography. is more accurate than arterial blood gases. provides intermittent measurements of O2.

is noninvasive.

With regard to dysfunctional uterine bleeding (DUB), the nurse should be aware that: it is most commonly caused by anovulation. it most often occurs in middle age. the diagnosis of DUB should be the first considered for abnormal menstrual bleeding. the most effective medical treatment involves steroids.

it is most commonly caused by anovulation.

With regard to the diagnosis and management of amenorrhea, nurses should be aware that: a. it probably is the result of a hormone deficiency that can be treated with medication. b. it may be caused by stress or excessive exercise or both. c. it likely will require the client to eat less and exercise more. d. it often goes away on its own.

it may be caused by stress or excessive exercise or both.

With regard to the use of tocolytic therapy to suppress uterine activity, nurses should be aware that: the drugs can be given efficaciously up to the designated beginning of term at 37 weeks. there are no important maternal (as opposed to fetal) contraindications. its most important function is to afford the opportunity to administer antenatal glucocorticoids. if the client develops pulmonary edema while on tocolytics, intravenous (IV) fluids should be given.

its most important function is to afford the opportunity to administer antenatal glucocorticoids.

A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on knowledge that: children tend to be overmedicated for pain. giving large doses of opioids causes euthanasia. narcotic addiction is common in terminally ill children. large doses of opioids are justified when there are no other treatment options.

large doses of opioids are justified when there are no other treatment options.

A neonate had corrective surgery 3 days ago for esophageal atresia. The nurse notices that after the child receives his gastrostomy feeding, there is often a backup of formula feeding into the tube. As a result, the nurse should: position the child in a supine position after feedings. position the child on his or her left side after feedings. leave the gastrostomy tube open and suspended after feedings. leave the gastrostomy tube clamped after feedings.

leave the gastrostomy tube open and suspended after feedings.

A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to: listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. continue to observe and make no changes until the saturations are 75%. continue with the admission process to ensure that a thorough assessment is completed. notify the parents that their infant is not doing well.

listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.

A woman at 35 weeks of gestation has had an amniocentesis. The results reveal that surface-active phospholipids are present in the amniotic fluid. The nurse is aware that this finding indicates: the fetus is at risk for Down syndrome. the woman is at high risk for developing preterm labor. lung maturity. meconium is present in the amniotic fluid.

lung maturity.

With regard to protein in the diet of pregnant women, nurses should be aware that: many protein-rich foods are also good sources of calcium, iron, and B vitamins. many women need to increase their protein intake during pregnancy. as with carbohydrates and fat, no specific recommendations exist for the amount of protein in the diet. high-protein supplements can be used without risk by women on macrobiotic diets.

many protein-rich foods are also good sources of calcium, iron, and B vitamins.

Nonpharmacologic strategies for pain management: may reduce pain perception. make pharmacologic strategies unnecessary. usually take too long to implement. trick children into believing that they do not have pain.

may reduce pain perception.

Cystic fibrosis may affect singular or multiple systems of the body. The primary factor responsible for possible multiple clinical manifestations is: atrophic changes in the mucosal wall of intestines. hypoactivity of the autonomic nervous system. hyperactivity of the sweat glands. mechanical obstruction caused by increased viscosity of mucous gland secretions.

mechanical obstruction caused by increased viscosity of mucous gland secretions.

A 4-year-old girl is brought to the emergency room. She has a "froglike" croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should: examine her oral pharynx and report to the physician. make her lie down and rest quietly. auscultate her lungs and make preparations for placement in a mist tent. notify the physician immediately and be prepared to assist with a tracheostomy or intubation.

notify the physician immediately and be prepared to assist with a tracheostomy or intubation.

With regard to medications, herbs, immunizations, and other substances normally encountered, the maternity nurse should be aware that: -prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus. -the greatest danger of drug-caused developmental deficits in the fetus is seen in the final trimester. -killed-virus vaccines (e.g., tetanus) should not be given during pregnancy, but live-virus vaccines (e.g., measles) are permissible. -no convincing evidence exists that secondhand smoke is potentially dangerous to the fetus.

prescription and over-the-counter (OTC) drugs that otherwise are harmless can be made hazardous by metabolic deficiencies of the fetus.

A 7-year-old female child has a fever associated with a viral illness. She is being cared for at home. The nurse should recognize that the principal reason for treating fever in this child is: relief of discomfort. reassurance that illness is temporary. prevention of secondary bacterial infection. prevention of life-threatening complications.

relief of discomfort.

The nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain: cannot occur if a child is comatose. may occur if a child regains consciousness. requires astute nursing assessment and management. is best assessed by family members who are familiar with the child.

requires astute nursing assessment and management.

When planning a diet with a pregnant woman, the nurse's FIRST action would be to: review the woman's current dietary intake. teach the woman about the food pyramid. caution the woman to avoid large doses of vitamins, especially those that are fat-soluble. instruct the woman to limit the intake of fatty foods.

review the woman's current dietary intake.

The nurse advises the woman who wants to have a nurse-midwife provide obstetric care that: she will have to give birth at home. she must see an obstetrician as well as the midwife during pregnancy. she will not be able to have epidural analgesia for labor pain. she must be having a low risk pregnancy.

she must be having a low risk pregnancy.

Most of the genetic tests now offered in clinical practice are tests for: single-gene disorders. carrier screening. predictive values. predispositional testing.

single-gene disorders.

The nurse should refer the patient for further testing if she noted this on inspection of the breasts of a 55-year-old woman: left breast slightly smaller than right breast. eversion (elevation) of both nipples. bilateral symmetry of venous network, which is faintly visible. small dimple located in the upper outer quadrant of the right breast.

small dimple located in the upper outer quadrant of the right breast.

A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because this environment facilitates: liquefying secretions. improving oxygenation. promoting ventilation. soothing inflamed mucous membrane.

soothing inflamed mucous membrane.

A woman is evaluated to be using an effective bearing-down effort if she: begins pushing as soon as she is told that her cervix is fully dilated and effaced. takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction. uses the Valsalva maneuver by holding her breath and pushing vigorously for a count of 12. continues to push for short periods between uterine contractions throughout the second stage of labor.

takes two deep, cleansing breaths at the onset of a uterine contraction and at the end of the contraction.

Concerning the third stage of labor, nurses should be aware that: the placenta eventually detaches itself from a flaccid uterus. the duration of the third stage may be as short as 3 to 5 minutes. it is important that the dark, roughened maternal surface of the placenta appear before the shiny fetal surface. the major risk for women during the third stage is a rapid heart rate.

the duration of the third stage may be as short as 3 to 5 minutes.

In order to accurately assess the health of the mother accurately during labor, the nurse should be aware that: the woman's blood pressure increases during contractions and falls back to prelabor normal between contractions. use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia. having the woman point her toes reduces leg cramps. the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.

the endogenous endorphins released during labor raise the woman's pain threshold and produce sedation.

With regard to hemolytic diseases of the newborn, nurses should be aware that: Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. exchange transfusions frequently are required in the treatment of hemolytic disorders. the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

the indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

With regard to the estimation and interpretation of the recurrence of risks for genetic disorders, nurses should be aware that: -with a dominant disorder, the likelihood of the second child also having the condition is 100%. -an autosomal recessive disease carries a one in eight risk of the second child also having the disorder. -disorders involving maternal ingestion of drugs carry a one in four chance of being repeated in the second child. -the risk factor remains the same no matter how many affected children are already in the family.

the risk factor remains the same no matter how many affected children are already in the family.

The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37° C. The nurse suspects croup and should recommend: controlling fever with acetaminophen and calling if the cough gets worse during the night. trying a cool-mist vaporizer at night and watching for signs of difficulty breathing. trying over-the-counter cough medicine and coming to the clinic in the morning if there is no improvement. admitting to the hospital and observing for impending epiglottitis.

trying a cool-mist vaporizer at night and watching for signs of difficulty breathing.

A pregnant woman at 32 weeks of gestation complains of feeling dizzy and light-headed while her fundal height is being measured. Her skin is pale and moist. The nurse's initial response would be to: assess the woman's blood pressure and pulse. have the woman breathe into a paper bag. raise the woman's legs. turn the woman on her side.

turn the woman on her side.

With regard to dysfunctional labor, nurses should be aware that: dysfunctional labor typically occurs in women who have a gynecoid pelvis. women who have dysfunctional labor are more likely to deliver via cesarean section. hypertonic uterine dysfunction is more common than hypotonic dysfunction. abnormal labor patterns are most common in older women.

women who have dysfunctional labor are more likely to deliver via cesarean section.

The nurse assessing a 9-year old boy who has been admitted to the hospital with possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? · Back pain for a few days · A history of hypertension · A sore throats last week · Diuresis during the nights

· A sore throats last week

A child who received multiple blood transfusions after correction of a congenital heart defects is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider? · CO combining power · Calcium · Sodium · Chloride

· Calcium

One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15.000/mm. What action should the nurse take first? · Check the differential, since the WBC is normal for this client · Assess the client's temperature, pulse, and respirations q4h · Assess the client's perineal area for signs of a perineal hematoma · Notify the healthcare provider, since this finding is indicative of infection

· Check the differential, since the WBC is normal for this client

2. During a well-child visit for their child, one of the parent who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder". How should the nurse respond? · Explain that the risk of inhering the disorder decrease by 50% with each child the couple has · Acknowledge that the next that the next child will inherit the disorder since the first child did not · Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked · Confirm that there is a 50% chance of their future children inheriting the disorder

· Confirm that there is a 50% chance of their future children inheriting the disorder

A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? · Turn the client to her left side · Contact the healthcare provider · Assess the fetal heart rate · Check the cervical dilation

· Contact the healthcare provider

A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2- station. What action should the nurse implement first? · Decrease the oxytocin infusion rate · Determine current cervical dilation · Request placement of the epidural · Give a bolus of intravenous fluids

· Determine current cervical dilation

A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? A. Obtain a culture of any sputum or wound drainage. · Obtain a culture of any sputum or wound drainage · Initiate normal saline IV at 50 ml/hr · Administer a loading dose of penicillin IM · Administer the initial dose of folic acid PO

· Initiate normal saline IV at 50 ml/hr

2. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? · Respiratory alkalosis · Respiratory acidosis · Metabolic acidosis · Metabolic alkalosis

· Metabolic acidosis

a child has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? · Respiratory alkalosis · Respiratory acidosis · Metabolic alkalosis · Metabolic acidosis

· Metabolic alkalosis

2. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? · Keep airway equipment at the bedside. · Allow liberal family visitation · Monitor blood pressure, pulse, and respirations q4h · Assess temperature q1h

· Monitor blood pressure, pulse, and respirations q4h

2. The nurse is caring for a one-year-old child following surgical correction of hypospadias. The nursing action has the highest priority? · Monitor urinary output · Auscultate bowel sounds · Observe appearance of stool · Record percent of diet eaten

· Monitor urinary output

A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? · Alert the neonatal team and prepare for neonatal resuscitation · Notify the healthcare provider from the client's bedside · Obtain written consent for an emergency cesarean section · Draw a blood sample for stat hemoglobin and hematocrit

· Notify the healthcare provider from the client's bedside

2. The nurse is measuring the frontal occipital circumference (FOC) of a 3- month-old infant, notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next? · Measure the infant's head to heel length · Observe the infant for sunset eyes · Palpate the anterior fontanel for tension and bulging · Plot the measurement on the infant's growth chart

· Palpate the anterior fontanel for tension and bulging

The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child? · Reduce cerebral edema and lower intracranial pressure · Avert hypotension and septic shock · Prevent cardiac arrhythmias and heart failure · Promote kidney perfusion and normal blood pressure.

· Reduce cerebral edema and lower intracranial pressure

2. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic (sudden aimless movements of the arms and legs). Which information should the nurse to the parents? · Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged · The chorea or movements are temporary and will eventually disappear · Permanent life-style changes need to be made to promote safety in the home · Consistent discipline is needed to help the child control the movements

· The chorea or movements are temporary and will eventually disappear